Skills: 38 points Objectives:

EXERCISE 6:

BLOOD CULTURE SPECIMEN COLLECTION

Skills:

38 points

Objectives: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

Differentiate between sterile and antiseptic techniques. Define the following terms: FUO, septicemia, bacteremia, aerobic and anaerobic. Describe the type of patient who may be a candidate for a blood culture. State specifically what blood cultures are used for. Discuss the interview process used for patient preparation when drawing blood culture samples especially iodine allergies. State the number of blood culture collections necessary for sufficient recovery of clinically significant microorganisms. Describe the different protocols used for the collection of blood cultures for systemic and localized infections and infective endocarditis. Define the term "second site" as it pertains to blood culture collection. State what the blood culture bottle or container has in it and the purpose it serves. List the materials and supplies necessary for collection of a blood culture specimen. State the reason that site preparation is so important in the collection of blood cultures. Compare and contrast the proper procedure for preparing a blood culture site using the iodine versus the chlorhexidine gluconate. State the advantage chlorhexidine gluconate products have over the traditional site preparation method. State the maximum allowable blood culture contamination rate. Define “false positive” and “false negative” as the terms relate to blood cultures. State two causes of false positive and false negative blood culture results. Discuss when the antibiotic removal device (ARD) bottles are used and how they work. Describe the ISOSTAT blood culture collection system and the purpose for it=s use. State how blood culture samples must be labeled. Perform a blood culture using proper collection and labeling techniques and with minimal trauma to the patient.

Discussion Blood cultures are collected whenever it is suspected that a patient has septicemia. Septicemia is a condition when microorganisms (mainly bacteria) circulate and multiply in the patient's blood. Sometimes, during the course of a bacterial infection, bacteremia (bacteria in the blood) may result and become the dominant clinical feature. The patient may have a fever of unknown origin (FUO) and experience fever spikes. It is generally recommended that blood cultures be drawn before and after the fever spike, when bacteria may be most likely present in the peripheral circulation. Blood culture analysis is usually ordered before the initiation of antimicrobial therapy, usually in a series, two to three blood cultures collected at least 1-2 hours apart. The blood culture analysis is used by physicians to rule out or confirm septicemia and/or bacteremia. 1 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

Syringe/Straight Needle When using a syringe/straight needle: 1. It is important to “breathe” the syringe prior to use. This is accomplished by moving the plunger back and forth in the barrel before using. This breaks the seal on the syringe. Failure to breathe the syringe may result in the needle being pulled from the vein when the seal breaks unexpectedly. The phlebotomist will be pulling hard on the plunger and when the seal is suddenly released too much force is being applied in a backward motion may result in the needle being pulled from the vein. 2. Once the needle is inserted into the vein the plunger should be pulled back gently, yet firmly. Pulling back on the plunger with excessive force to speed blood coming into the syringe may cause the vein to collapse or, if extreme pressure is applied, may cause hemolysis of the blood sample. Patient Preparation Explain to the patient, if they are coherent, that the physician has ordered a series of tests and you will have to draw their blood several times at timed intervals. Any additional questions about the procedure need to be referred to the physician. Do not volunteer any additional information.

Collecting the Specimen Blood is normally sterile; the presence of microorganisms and their products is very serious and can cause death. A blood culture will indicate the severity of an infection and identify the causative organism. Normal values are negative for growth. It is best to draw one set of aerobic (containing oxygen) and anaerobic (without oxygen) cultures at the time the order is given. Thirty minutes later, a second set of anaerobic and aerobic cultures should be obtained. A request for "second site" blood cultures that are obtained concurrently on opposite arms is useful when the physician suspects bacteremia due to a local internal infection. However, a "second site" culture is not a very effective tool for routine blood culture orders and provides relatively little information that properly spaced, timed blood cultures cannot provide. Recent reports recommend that in most instances two blood culture sets are sufficient for recovery of significant microorganisms, particularly with the increased blood volume collected. There is greater than 99 percent recovery with only two sets. Blood Culture Collection Protocols Blood culture collection protocols may be set up and designed to detect bacteremia in certain disease state suspected or symptoms that the patient is exhibiting. Commonly accepted protocol for obtaining blood cultures are as follows: 1. Systemic and localized infections a. Suspected acute sepsis, meningitis, osteomyelitis, arthritis or acute untreated bacterial pneumonia. Obtain two blood culture sets before starting therapy from 2 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

two separate sites (eg, left and right arms). b. Fever of unknown origin (FUO). Obtain two blood culture sets initially; 24 to 36 hours later, obtain two more. More than four sets are not necessary. c. Suspected early typhoid fever and brucellosis (rarely seen). Obtain three blood culture sets over 24 to 36 hours. 2.

Infective endocarditis; a.

b.

Obtain three blood culture sets at three separate venipuncture sites during the first one to two hours of evaluation and begin antimicrobial therapy; if all are negative 24 hours later, obtain two more sets. Culture negative endocarditis. Consult with the microbiology department after five negative cultures. Culture negative endocarditis is extremely rare.

Site Preparation The most critical step in collecting a blood culture is the proper cleansing of the site. Bacteria are normally present on the skin surface. It is imperative for quality test results that bacteria is NOT introduced into the specimen being collected. Before the collection of a specimen for blood culture analysis, the selected venipuncture site must be prepared by aseptic technique. Routine venipunctures require an antiseptic to be used on the site. Blood culture collections require a sterile site, one that is free of living microorganism. Due to the special site preparation once the site has been prepared DO NOT REPALPATE! Repalpating the site will contaminate it. The traditional method involves first cleansing the site for 60 seconds with alcohol to remove the oils and dirt on the skin surface. The site is then painted with a 2 percent tincture of iodine solution which is allowed to dry to kill surface skin bacteria. If this procedure is used the patient must be asked about allergies to iodine. If the patient does have an iodine allergy, the only recourse is to cleanse thoroughly with 70 percent alcohol a second time, the use of green soap or another method. The iodine is painted on the area, with a circular motion, starting at the site of the puncture and moving in concentric circles outward. Do not flood the site. Iodine is an effective antiseptic only if it is allowed to dry before the venipuncture is attempted. The cleansing procedure varies from one laboratory to another. The newest method to prepare the site uses a less toxic product called chlorhexidine gluconate. Chloraprep swabs and Chlorascrub swabs utilize this chemical.Both of these methods are one-step applications of the chlorhexidine gluconate and 70% isopropyl alcohol. The Chloraprep swab solution comes in an ampule attached to a scrubbing sponge. The handle is squeezed to break the ampule and dispense the solution and the site is scrubbed firmly for 30 seconds to disinfect the site and allowed to dry for one minute. The Chlorascrub swab requires a 15 second prep time. Both methods are quicker and lead to better compliance in preparation of sites for blood culture collection. In theory this should lead to fewer contaminated blood culture collections. 3 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

The seals on the bottles are broken off. This seal usually consists of a metal flip off cap. Under the seal is a rubber septum through which the needle is inserted. Once the flip off cap is removed, the septum is cleaned with an alcohol pad. Allow the alcohol to dry for 60 seconds. The proper amount of blood is drawn with a syringe. The bottles are inoculated with blood using a safety transfer device. Always fill the anaerobic bottle first to maintain a strict anaerobic environment. Instead of using a syringe to draw the blood and inoculate the bottles, a butterfly collection set can be used. An adapter can be attached to the end of the butterfly which attaches to the blood culture bottle and directly inoculates the bottle with blood. Each bottle is filled to the proper level of blood. There are also blood culture bottles with long necks that insert into an evacuated needle holder. These are the preferred methods because they minimize the chance of contamination due to the blood being drawn directly into the prepared tube. It is critical that the tops of the tubes be cleansed prior to collection. When multiple tubes of blood are collected are needed, blood cultures are always collected first. With all blood culture methods, there are some variations in procedure for the phlebotomist. The arm cleansing technique may differ. Some blood culture systems must have the aerobic bottle vented (air added) by the phlebotomist. A variation in procedure does not indicate the laboratory is improper but illustrates variations in manufacturer’s directions. Blood Culture Collection Systems The blood is collected and placed in a bottle containing a solution that enhances the growth of significant microorganisms if they are present. An anticoagulant is also present. The Isostat System is a special blood culture tube system which has a stopper that fits standard blood collection vacuum holders, lysing and anticoagulating agents, reagents in the tube that inactivate HIV within the normal 60 minute transport and processing time and containment adapters that help protect the phlebotomists and laboratorians against infection due to aerosols or breakage during centrifugation. After blood is drawn into the tube it is inverted 5 to 6 times. The blood cells in the tube lyse, the tube is centrifuged in the microbiology laboratory, and the sediment is then inoculated directly on solid culture media to determine if microorganisms are present. Using this tube affords the advantage of faster microbial test results. Labeling the Specimen When labeling blood culture specimens, routine labeling procedures should be followed. In addition, the label should include the site used for collection and the number of the sample in the collection series (example: R arm, 2nd of 3). Sites are varied throughout the series of blood culture collection to increase the rate of recovering pathogenic bacteria. Consequently, the blood culture specimens should be labeled with the collection site and the sequence in the collection series as a point of reference for the subsequent draw. In addition, the site of collection and the sequence in the collection series may impact the interpretation of the results. Therefore, the information must be available to the technologist and the attending physician. 4 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

Quality Control in Blood Culture Collection Quality control in blood culture collection involves following procedures exactly to prevent false positive or false negative results in the blood culture. False Positive This is a blood culture which grows organisms but the organisms were NOT present in the patient’s blood. This is caused by collecting the blood culture from an improperly prepared site, which results in the blood culture bottles being contaminated with microbial flora (organisms) from the skin. This is also known as a “contaminated” blood culture. Contamination of blood culture specimens should be limited to less than 3% (i.e., less than 3 out of every 100 positive blood cultures should be the result of contamination during the blood collection procedure). If the microbiology department determines that the contamination rate exceeds 3%, it will investigate. The phlebotomists who collected the contaminated cultures will be identified, and their technique will be evaluated and, if necessary, modified to be in compliance with the procedure. If the microorganism recovered is recognized as a common skin contaminant (eg, Staphylococcus epidermidis or Corynebacterium), one might think it could be safely ruled out as the causative organism of the patient's bacteremia. However, in certain conditions, such as infective endocarditis (especially in prosthetic heart valves), the causative organism may be one of the microorganisms commonly referred to as "skin contaminants." Therefore, preparation of the venipuncture site prior to the collection of a specimen for blood culture analysis must be meticulously performed to reduce the contamination of blood culture specimens with microbial flora of the skin. To accomplish this, the phlebotomist should: 1. Use appropriate cleansing agents. 2. Apply the cleansing agents in the appropriate order. 3. NEVER repalpate the site after it was cleansed by aseptic technique. False Negative The blood culture may not grow organisms (be negative) yet the patient is suffering from sepsis. There are many causes of false negatives such as: 1. The causative organisms being present in very small numbers which may not be detected if the proper volume of blood is not collected. The volume of specimen collected is critical to the validity of test results. 2. Contamination of the blood specimen with cleansing agent. Iodine contamination is usually the result of excess iodine on the stopper prior to inoculation or not allowing the iodine on the patient's arm to dry. 3. If an excessive amount of blood is collected it may clot in the collection tube, rendering recovery of microorganisms difficult if not impossible. 5 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

4. Injection of air into the anaerobe bottle can cause death of some anaerobic microorganisms and result in a false negative. For this reason, the anaerobe bottle must be inoculated first. Physicians may believe a false negative has occurred when the blood cultures are negative yet the patient still exhibits signs of sepsis. In summary, the proper collection of quality blood culture specimens is of critical importance. False positive and false negative results are often directly related to the technique used by the phlebotomist. Septicemia may cause the death of the patient and must be diagnosed as quickly as possible so appropriate therapy can be initiated.

6 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

EXERCISE 6: BLOOD CULTURE SPECIMEN COLLECTION Procedure Materials 1. 2. 3. 4. 5. 6. 7. 8. 9.

Gloves Iodine Swabs, Chloroprep or Chlorascrub swabs Alcohol Swabs Bio wipes or gauze Syringe Needle for the syringe Safety Transfer Device Blood collection tubes/bottles Sharps Container and Trash Can

Instructions: 1. Approach the patient, identify yourself as a student, and ask for verbal permission to proceed. (Observer records time.) 2. Properly identify the patient. Ask the patient to state their name, spell it, and date of birth. 3. Wash or sanitize hands. 4. Put on gloves. 5. Ask about blood drawing history. 6. Explain to the patient that their physician has ordered a test requiring a series of venipunctures. Explain that the venipuncture procedure will be performed several times over a particular time span. Ask the patient about allergies to iodine if traditional method is used. 7. Apply the tourniquet properly. 8. Ask patient to clench fist. 9. Palpate for suitable veins using your index finger. Note the size, direction and depth of the veins. 10. Select an appropriate vein based on selection criteria: 1) median cubital, 2) cephalic, 3) basilic. 11. Release the tourniquet within 1 minute of application. 12. Open the syringe package and “breathe” the syringe by moving the plunger back and forth several times. Open the needle and attach the needle to the syringe. Verify that the safety transfer device is available. 13. Clean the site using appropriate techniques and time frame as per manufacturer’s instructions. a. Traditional - scrub site with alcohol for 1 minute, paint site with iodine and allow to dry completely. b. Chloroprep - scrub site for 30 seconds, allow to dry for 1 minute. c. Chlorascrub Swab – scrub site for 15 seconds allow to dry for 30 seconds. 14. Allows site to dry as specified by manufacturer instructions. 15. Swab tops of bottles/tubes with alcohol and allow to dry for 1 minute. 16. Reapply the tourniquet. Be careful that the ends of the tourniquet do not fall onto the puncture site, thereby contaminating it. If the tourniquet does accidentally touch the 7 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

27. 28. 29. 30.

31. 32. 33.

34.

35. 36.

37. 38.

prepared puncture site, the site must be re-cleaned. Ask patient to gently clench fist. Correctly positions the syringe between the thumb and index finger. Uncaps the needle and briefly inspects needle for defects. Properly anchors vein with the thumb. Do not repalpate! Insert needle swiftly, bevel up, in same direction as the vein at the correct angle using sterile technique. Stabilizes syringe by maintaining contact between the patients’ arm and back of phlebotomist’s fingers Pulls back on the plunger with firm, gentle pressure to collect the appropriate amount of blood. Release tourniquet. Places Biowipe or gauze over the puncture site, gently removes needle from patient without applying pressure on Biowipe or gauze. Immediately activate the needle safety device with one hand according to manufacturer’s directions while applying pressure to the site with the other hand. Do not remove your other hand from the puncture site until the safety device is activated! Ask patient to apply pressure to the puncture site. Remove needle from syringe and discard needle in sharps container. Attach the syringe to the appropriate Safety Transfer Device. Position the syringe with the plunger facing up and the Safety Transfer Device below. Insert the anaerobic blood culture bottle or appropriate test tube into the Safety Transfer Device and allow the appropriate amount of blood to flow into the bottle or tube. Remove the anaerobic bottle or tube, insert the aerobic bottle or tube and allow it to fill. If other blood tubes are to be collected, fill them in the correct order of the draw after the blood culture specimens. Discard the used syringe with the attached Safety Transfer Device into the sharps container. Mix the filled bottles or tubes by gentle inversion according to the manufacturer’s directions. Label the blood specimen using standard labeling procedures, plus the site used and the number of the specimen in the series ordered. Carefully show the correctly labeled bottles or tubes to the patient and ask them to verify their name and date of birth. Inspect puncture site to verify that bleeding has stopped, apply bandage if needed. If bleeding has not stopped, continue to apply pressure. Recheck site at one minute intervals until bleeding has stopped. Thank the patient. Leave patient courteously. Allow patient to leave if they are an outpatient. Disinfect work area and discard waste materials following standard procedures. REMEMBER: gloves, biowipes, paper wrappings, needle caps and other nonbiohazardous materials DO NOT GO IN THE BIOHAZARD SHARPS CONTAINER!!! Remove gloves and immediately wash or disinfect hands. (Observer records time.) Have your partner complete the “Blood Culture Venipuncture Practice Skills Assessment Form”. Record the draw on your venipuncture log sheet. 8 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

EXERCISE 6: BLOOD CULTURE SPECIMEN COLLECTION STUDY QUESTIONS

Name______________________________________Date_________________ Points _________/26

Points: 26 1.

Define "septicemia" (0.5 point).

2.

Define "bacteremia" (0.5 point).

3.

What does "FUO" standard for (0.5 point)?

4.

What is a blood culture specifically used for (1 point)?

5.

Describe the manner in which you would verbally prepare a patient prior to collection of the blood culture sample (1 point).

6.

Define "aerobic" (0.5 point).

7.

Define "anaerobic" (0.5 point).

8.

Define the term "second site" as it pertains to blood culture collection (1 point).

9.

What is the minimum number of blood cultures which must be collected to obtain greater than 99 percent recovery of pathogenic organisms (0.5 point).

9 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

10.

Describe the protocol utilized for collecting blood cultures when systemic and localized infections are suspected for each of the following (3 points): a.

Acute sepsis, meningitis, osteomyelitis, arthritis or bacterial pneumonia

b.

Fever of unknown origin.

c.

Early typhoid fever or brucellosis

11.

Describe the protocol utilized for collecting blood culture specimens when infective endocarditis is suspected (2 points).

12.

What is the most critical step involved in obtaining the blood culture specimen. (0.5 point).

13.

Describe in detail the steps in the TRADITIONAL manner for preparing the site for collection of a blood culture (2 points).

14.

What question should be asked of the patient prior to drawing a blood culture using the traditional method? Why? (1 point)

10 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

15.

Describe in detail the steps in the procedure using the two following products for preparing the site for collection of a blood culture (2 points). A. ChloraPrep

B. Chlorascrub Swab 16.

State the chemicals present in the ChloraPrep and Chlorascrub products. (1 point)

17.

State the advantage ChloraPrep and Chlorascrub have over traditional site preparation methods. (1 point)

18.

What does the blood culture bottle or container have in it and what purpose does it serve? (1 pt). A. B.

19.

Describe in detail the Isostat System for collection of blood cultures (1.5 points).

20.

Describe the special labeling requirements for blood culture specimens (1.5 points). A. B. C.

21.

Define "false positive" as it relates to blood culture specimens AND state the most common cause (1 .5 point). A. B.

21.

Define "false negative" as it relates to blood culture specimens AND state one cause (1.5 point). A. B.

22.

Contamination of blood cultures should not exceed what percent of the total collected (0.5 point).

11 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

Phlebotomy Technician Program BLOOD CULTURE Venipuncture Practice Skills Assessment Form Revised: August 12, 2015 Practice Draw

Live Draw

Check ONE of the following:

Vacuum tube

Butterfly/Vacuum

Butterfly/Syringe

Needle/Syringe

X

Phlebotomist (PRINT): ______________________________ Date: ________________ Partner or Instructor (PRINT): ___________________________________________________ Instructions: The activity is to be started by the phlebotomist’s introduction. Evaluator is to place a “” in the appropriate column. ALL critical areas (shaded boxes) must be performed within the allotted time to pass skills test. Performed Not Skills TIME LIMIT: 20 minutes

Performed

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

Introduces self as student and states mission. * Record Start Time Here ___________________* Properly identifies patient. Washes or sanitizes hands. Puts on gloves Asks about blood drawing history Explains blood culture collection procedure; including inquiring about iodine allergy. Applies tourniquet properly Asks patient to gently clench fist Properly palpate appropriate veins to be used for venipuncture Choose acceptable vein according to appropriate selection criteria. Releases tourniquet Selects and prepares appropriate equipment. Breaths the syringe Cleanses site using appropriate technique AND time frame as per manufacturer’s instructions Allows site to air dry as specified by manufacturer’s instructions Cleanses the top of the collection container with ALCOHOL, and allows it to air dry Applies tourniquet without contaminating the venipuncture site. Asks patient to gently clench fist Correctly positions the syringe between the thumb and index finger Uncaps the needle and briefly inspects needle for defects Properly anchors vein with thumb and DOES NOT REPALPATE SITE Inserts needle swiftly, bevel up, in same direction as the vein at the correct angle using sterile technique. Stabilizes syringe by maintaining contact between the patients’ arm and back of phlebotomist’s fingers. Pulls back on the plunger with firm, gentle pressure to collect the appropriate amount of blood. Releases tourniquet Places biowipe/gauze over puncture site, gently removes needle. Immediately activates needle safety device according to manufacturer’s instructions with one hand while applying pressure to site with other hand. 27. Asks patient to apply pressure to puncture site. 28. Remove needle from syringe and discards needle in sharps keeper. 29. Attach the syringe to the appropriate Safety Transfer Device with the plunger facing up. 30. Plug in the anaerobic blood collection bottle or appropriate test tube allowing it to draw the designated amount of blood. Repeat with the aerobic blood culture bottle or tube. 31. Discard the used syringe with the attached Safety Transfer Device into the sharps container 32. Mix the filled bottles or tubes by gentle inversion according to manufacturer’s directions. 33. Label the filled bottles or tubes with the correct information. Patient initials____ Instructor Initials ____ 34. Inspects puncture site to make sure bleeding has stopped, applies bandage if necessary. 35. Leaves patient courteously. 36. Disinfects work area. 37. Removes gloves and immediately washes or disinfects hands. * Record End Time Here ____________* 38. Skill performed within allotted time. *Record Total Time Here _________* Total Number of Checks Comments (continue on back as necessary):

12 Exercise 6: Blood Culture Collection (Rev 2/08/2016)

Phlebotomy Technician Program BLOOD CULTURE Venipuncture Practice Skills Assessment Form Revised: August 12, 2015 Practice Draw

Live Draw

Check ONE of the following:

Vacuum tube

Butterfly/Vacuum

Butterfly/Syringe

Needle/Syringe

X

Phlebotomist (PRINT): ______________________________ Date: ________________ Partner or Instructor (PRINT): ___________________________________________________ Instructions: The activity is to be started by the phlebotomist’s introduction. Evaluator is to place a “” in the appropriate column. ALL critical areas (shaded boxes) must be performed within the allotted time to pass skills test. Performed Not Skills TIME LIMIT: 20 minutes

Performed

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

Introduces self as student and states mission. *Record Start Time Here_____________* Properly identifies patient. Washes or sanitizes hands. Puts on gloves Asks about blood drawing history Explains blood culture collection procedure; including inquiring about iodine allergy. Applies tourniquet properly Asks patient to gently clench fist Properly palpate appropriate veins to be used for venipuncture Choose acceptable vein according to appropriate selection criteria. Releases tourniquet Selects and prepares appropriate equipment. Breaths the syringe Cleanses site using appropriate technique AND time frame as per manufacturer’s instructions Allows site to air dry as specified by manufacturer’s instructions Cleanses the top of the collection container with ALCOHOL, and allows it to air dry Applies tourniquet without contaminating the venipuncture site. Asks patient to gently clench fist Correctly positions the syringe between the thumb and index finger Uncaps the needle and briefly inspects needle for defects Properly anchors vein with thumb and DOES NOT REPALPATE SITE Inserts needle swiftly, bevel up, in same direction as the vein at the correct angle using sterile technique. Stabilizes syringe by maintaining contact between the patients’ arm and back of phlebotomist’s fingers. Pulls back on the plunger with firm, gentle pressure to collect the appropriate amount of blood. Releases tourniquet Places biowipe/gauze over puncture site, gently removes needle. Immediately activates needle safety device according to manufacturer’s instructions with one hand while applying pressure to site with other hand. 27. Asks patient to apply pressure to puncture site. 28. Remove needle from syringe and discards needle in sharps keeper. 29. Attach the syringe to the appropriate Safety Transfer Device with the plunger facing up. 30. Plug in the anaerobic blood collection bottle or appropriate test tube allowing it to draw the designated amount of blood. Repeat with the aerobic blood collection bottle or tube. 31. Discard the used syringe with the attached Safety Transfer Device into the sharps container 32. Mix the filled bottles or tubes by gentle inversion according to manufacturer’s directions. 33. Label the filled bottles or tubes with the correct information. Patient initials____ Instructor Initials ____ 34. Inspects puncture site to make sure bleeding has stopped, applies bandage if necessary. 35. Leaves patient courteously. 36. Disinfects work area. 37. Removes gloves and immediately washes or disinfects hands. * Record End Time Here ____________* 38. Skill performed within allotted time. *Record Total Time Here ___________* Total Number of Checks Comments (continue on back as necessary):

13 Exercise 6: Blood Culture Collection (Rev 2/08/2016)